Tag: Billing

Simple Bills are Not So Simple

Jan 5, 2022

By MATTHEW HOLT

I went for an annual physical with my doctor at One Medical in December. OK it wasn’t actually annual as the last time I went was 2 & 1/2 years ago, but it was covered under the ACA, and my doc Andrew Diamond was bugging me because I’m old & fat. So in I went.

I had a general exam and great chat for about 45 minutes. Then I had blood work & labs (cholesterol, A1C, etc) and a TDAP vaccination as it had been more than 10 years since I’d had one.

Today, about one month later, I got an email asking me to pay One Medical. So being a difficult human, I thought I would go through the process and see how much a consumer can be expected to understand about what they should pay.

Here’s the email from One Medical saying, “you owe us money.”

Suit Says Test Labs Cheat Medicare, Medicaid

Sep 1, 2018

By MERRILL GOOZNER

Despite recent court settlements that recouped more than a quarter billion dollars from lab-test companies for allegedly overbilling California’s Medicaid program, the federal government seems to be ignoring similar schemes that drain Medicare coffers.

The cases involve the nation’s two largest medical laboratory-testing companies – Laboratory Corporation of America and Quest Diagnostics – that together control about half the annual $25 billion lab test market. The Medicare suits, filed in federal court in Manhattan by a former industry executive, claim the testing companies charged insurers like UnitedHealthcare unprofitably low rates while squeezing Medicare and Medicaid.

The whistleblower suits allege the schemes relied on sweetheart deals in which managed-care companies required in-network physicians to send their patients’ lab tests to a single testing company. As part of the deal for below-cost prices, the insurance companies allegedly promised to encourage physicians in their networks also to send Medicare and Medicaid patients to the same testing company, which then billed the Centers for Medicare and Medicaid Services (the federal agency that oversees both programs) or state Medicaid agencies at significantly higher rates.

Patients are NOT Customers

Mar 21, 2015• 27

By SHIRIE LENG, MD

Recently I wrote about the problems with Maintenance of Certification requirements. One of the phrases I read repeatedly when I was researching the piece was “the patient as customer.” Here’s a quote from the online journal produced by Accenture, the management consulting company:

Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.

Except for one thing. Patients are NOT customers.

The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money. Customers can buy either goods or services. Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing. If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price. Even a vacation, especially a vacation package or a cruise, is a good. A nice dinner, while a good in the sense of the food, is also a service. You buy the services of the cook and servers.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

1. Patients are not on vacation. They are not in the mindset that they are sitting in the doctors office or the hospital to have a good time. They are not relaxed, they have not left their troubles temporarily behind them. They have not bought room service and a massage. They are not in the mood to be happy. They would rather not be requiring the service they are requesting. Which leads to number 2:

2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases.

3. Patients are not paying for the service. At least not directly. And they have no idea what the price is anyway.

4. Patients are not buying a product from which they can demand a positive outcome. Sometimes the result of the service is still illness and/or death. This does not mean the service provided was not a good one.

5. The patient is not always right. A patient cannot, or should not, go to a doctor demanding certain things. They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs. The doctor is not a servant; she does not have to do everything the patient wants. She is obligated to do everything the patient needs.

6. Patient satisfaction does not always correlate with the quality of the product.A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care. A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.

What If Restaurant Bills Looked Like Hospital Bills?

Mar 15, 2015• 8

By THCB MD

You’d get something like this:

HAT TIP: Jeanne Pinder. WHHY Philadelphia. Learn more about Pinder and her project here.

How Much Is My Colonoscopy Going to Cost? $600? $5,400?

Aug 27, 2014• 88

By JEANNE PINDER

How much does a colonoscopy cost? Well, that depends.

If you’re uninsured, this is a big question. We’ve learned that cash or self-pay prices can range from $600 to over $5,400, so it pays to ask.

If you’re insured, you may think it doesn’t matter. Routine, preventive screening colonoscopies are to be covered free with no co-insurance or co-payment under the Affordable Care Act.

However, we’re learning that with colonoscopies, as with mammograms, people are being asked to pay sometimes. It’s not clear to us in every case that they should pay, and since we don’t know all the details of these events, we can only offer some general thoughts. We’ve also heard from Medicare enrollees without supplemental Medicare policies that they think they’re responsible for 20 percent of the charged price — so 20 percent of $600 vs. 20 percent of $5,400 is a big deal.

If you’re on a high-deductible plan and the charge to you will be, say, $3,600, you can probably ask around and find a lower rate.

A thorough view of some colonoscopy billing issues is in this article in The New York Times by Libby Rosenthal, who has been covering health costs for the paper. We’ve heard also about in-network providers using out-of-network anesthesiologists, so it pays to pay attention.

A Modest Proposal: Charting Day

May 10, 2014• 14

By JEFF GOLDSMITH

At the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes ).

The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.

In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem , I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle.

Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.

Physicians, nurses, and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.

Hospitals are solving this problem with a medieval remedy: scribes who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets. Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.

The Medical Chart: Ground Zero for the Deterioration of Patient Care

Apr 25, 2014• 32

By Val Jones, MD

EMR Alert – Featuring radiologist note in illegible font color

For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.

I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.

I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.

This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.

While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.

What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?

Overcharged 38000% !!!

Dec 17, 2013• 80

By THCBist

Pretty Grumpy in NC writes in :

I am writing this letter as a complaint about medical charges from Wake Forest Baptist Medical Center, which I think is excessive.

I would like to point out that I got excellent care during my stay at Wake Forest Baptist Medical Center. I am questioning charges in total of $763.50. I received my bill for my hospital stay for surgery on June 10, 2013. I noticed a charge categorized as “Cast Room” of $763.50. I called the billing department and asked for an itemized bill.

I received the itemized bill and discovered that the “Cast Room” bill was really a daily charge of $254.50 for “Basic Frame with trapeze”. I called about this charge and learned that it was the bar above the bed attached to foot of bed to the head of the bed along with a trapeze handle. This item is used to help get up out of bed.

I think these charges are excessive.

I contacted a local home health equipment company to see what the charge would be if I rented this piece of equipment, and they told me the same item is $20 per month! This just seems unbelievable that a hospital can charge over 38000% above the price I can get this equipment for my home.

The Most Important Thing (code: e.280.11) I didn’t Learn in Med School (code: 780.92)

Jun 3, 2013• 10

By Jessica Jou

Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room. There, he was triaged by the nurse (nursing report #1) and vitals were taken (nursing report #2). Shortly after the mother and son pair settled into the pediatric emergency room, he vomited once (code 787.03).

The emergency medicine residents came by an hour later to conduct a focused interview, and performed a comprehensive physical exam (code: 89.03). He took care to ask at least four elements of the history of present illness that included location, quality severity, duration, timing, context, or associated symptoms from the event. He performed a complete review of at least 10 organ systems and surveyed the patient’s social history (code: 99223). It was decided that the boy was to be observed in the ED for the next few hours for signs of brain injury or concussion.

No labs or imaging studies were ordered. The nurses were instructed to check for vital signs every hour (nursing reports #3,4,5,6). During the observation period, the boy was found to be active, interacting well with mom, hungry, without signs of lethargy or focal neurologic deficits. When the attending physician came by to evaluate and assess the patient, he agreed with the resident’s report and signed the discharge note. The mother was given discharge paperwork and instructions for returning to the hospital if she noticed any new, alarming symptoms.

This is what Kelly, an emergency department medical coder, gathers while reading an ED admission note. She turns to me and explains that the few lines of attending attestation are the only way the patient can get billed. Kelly types in “959.01” into her software because she memorized the diagnosis code for “head injury, unspecified.” She has been doing this for the last 18 years.

As I listened, she explained that a head injury in a twelve-month-old infant is automatically a level three, so long as the resident documents a review of ten systems, past medical history, and a physical exam. These levels indicate the complexity and severity of the patient’s disease/injury. “It’s all about the documentation,” she says. “If just 9 organ systems instead of 10 are documented, even a critically ill patient could be down-coded to a level 4.”

More Explanation of the Explanation of Benefits (EOB)

Oct 24, 2011• 1

By DAVID E. WILLIAMS

A few weeks ago I parsed an Explanation of Benefits (EOB) I received from Blue Cross Blue Shield of Massachusetts after a visit to Sports & Physical Therapy Associates, an excellent physical therapy center with 14 locations in Greater Boston. The post (What does an Explanation of Benefits (EOB) actually explain?) generated a number of comments and questions on the Health Business Blog itself and when it was cross-posted at KevinMD. In particular:

What would a cash paying patient be asked to pay?
How is the $225 in “charges” derived? Is it determined by Medicare?
Does the provider lose money on the Blue Cross contracted rate?

I’m not a billing expert so I sent an email to Sports & PT to ask them to respond directly. I was impressed with their informative and thorough response, which I am posting here with their permission.

Mr. Williams,

We would be happy to provide you with some insight into how insurance claims are processed. Please find your questions with the corresponding answers below.

When a patient first comes to our clinics, we provide them our Policy Disclosure document. I think you will find it valuable in understanding the relationship between patient and provider, patient and insurance carrier, and lastly, provider and insurance carrier. Here is the first paragraph:

“Sports and Physical Therapy Associates (SPTA) is pleased to participate in your health care and we look forward to establishing a lasting relationship as your physical therapy provider. As part of this relationship, we wish to establish our expectations of your financial responsibility as outlined in our Financial Policy. Letting you know in advance of our Financial Policy allows for a good flow of communication and enables us to better satisfy you. Your medical insurance is a contract between you and your insurance company; we are not a party to that contract. We can often help with providing information about your benefits, but you are primarily responsible for knowing what type of coverage you have and for any charges that you have incurred as a patient with us. Please review and sign the following Financial Policy prior to your first visit.”